Referral Form

Use of this referral form is the first step in the process for The Barry Robinson Center to consider your child for treatment services. Submission of this form will be followed up with a phone call.

May we contact you by phone?: *

Child's Name: *

Date of Birth: *

Gender: *

Referral Source Name and Address: *

Referral Source Phone Number: *

Legal Guardian Name and Address (if different from Referral Source):

Legal Guardian Phone Number:

Reason for Referral: *

Type of Treatment Requested: *

Is the Child Currently in Treatment?: *

If yes, Name of Provider:

Current Placement

Home

Other Treatment Facility

Detention Facility

Foster Care

Treatment Facility Name and Dates:

Detention Facility Names and Dates:

Foster Care Name and Dates:

Current Psychiatric Diagnosis

Axis I:

Axis II:

Axis III:

Axis IV:

Axis V:

Current Medications:

Education Information

School Attending:

Current Grade:

IEP:

Spec. Ed. Classification:

Involvement with the Legal System:

If yes, describe the reason:

Type of Insurance:

Have you been to FAPT?:

Additional Required Information to be mailed or faxed:

Psychiatric or Psychological Evaluation(s)
Treatment records including outpatient provider records, inpatient records, etc.
Social History
Medical History
School Information
Other information may be requested as needed.

Accredited By: The Joint Commission, Virginia Association of Independent Specialized Education Facilities
Licensed By: Virginia Department of Behavioral Health and Developmental Services, Virginia Department of Education, Virginia Department of Social Services

Referrals

Request a Brochure

Do you need help?

Referral Form

Additional Required Information to be mailed or faxed: